| NPI | 1760990105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NE 2212) |
| 363AM0700X Physician Assistant, Medical | |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2018-01-19 |
| Last Update Date | 2019-09-11 |